Clinical profile and neuroimaging in pediatric optic neuritis in Indian population: A case series

A STUDY ON CLINICAL PROFILE AND OUTCOME OF VISUAL PARAMETERS OF OPTIC NEURITIS PATIENTS IN A TERTIARY EYE CARE CENTRE

Introduction: Optic neuritis (ON) is the inflammation of the optic nerve secondary to autoimmune, infectious, or inflammatory conditions. Objective: The objective is to study the clinical profile and changes in visual parameters after the treatment of patients with ON. Methods: This prospective interventional research was done at the ophthalmology department of a tertiary eye care center. 36 cases diagnosed with ON have been analyzed, treated, and followed up for 1 year, for the type of clinical presentation, rate of recurrence, and changes in visual parameters. Results: The prevalence rate was bimodal, more common among age groups between 46 and 55 years at 32% and age group 16–25 at 27%. A higher prevalence rate was seen in females in 63% of cases. The bilateral presentation was observed in 18%. 44% of cases presented as retrobulbar neuritis (RBN) whereas 56% were as papillitis. At 1 year follow up Optic disc edema suggestive of papillitis was seen in 17% of cases, normal disc with RBN in 44% and disc pallor in 32% discs. At the final follow-up after 1 year, 75% of patients could read maximum (10/13) color plates, 64% of cases showed standard contrast sensitivity and 47% showed normal visual field. VA of 6/60 or worse at presentation was seen in 53% cases and <6/12 in (84%) cases which improved to better than 6/12 in 58% cases and better than 6/60 in 67% cases at final follow up at 1 year. The most common visual field abnormality at presentation was generalized field constriction in (34%), central or centrocecal scotoma in (18%), hemianopia or quadrantanopia (12%), and enlarged blind spot in (06%) cases. During the final follow-up at 1 year, 22 cases (61%) showed normal field. Visual Field could not be tested in (30%) at presentation as vision was <3/60, although visual evoked potential was abnormal in all of 36 (100%) cases with mean P 100 latency being 128 ms. Furthermore, 3 (8%) cases demonstrated additional neurological symptoms till the final follow-up and were subsequently identified to be multiple sclerosis (MS). Recurrence rate was 08 (22%) within 1 year follow-up, of which 06 (17%) cases were clinically RBN and 02 (05%) were papillitis. Conclusion: In our study, findings of clinical profile and visual outcomes of ON patients were different from that of Western studies as well as from those done previously in the Indian population, notably lesser prevalence of MS, although other differences were not very significant.

Characteristics of Optic Neuritis in South Korean Children and Adolescents: A Retrospective Multicenter Study

Purpose

To analyze the clinical characteristics and prognosis of optic neuritis (ON) in pediatric patients aged <19 years in South Korea.

Methods

This multicenter retrospective cohort study included 127 pediatric patients (median age: 10.3 (IQR: 7.3–14.2) years; female, 62.2%) who experienced ON for the first time between January 2004 and January 2018, with data obtained from five tertiary university-based hospitals in Korea. When ON was bilateral, the worse eye was selected for analysis. The baseline clinical characteristics and prognoses of patients, as well as the associations between these parameters, were analyzed.

Results

The baseline clinical characteristics of the patients were as follows: best-corrected visual acuity (BCVA) < 20/200, 65.9%; pain on eye movement, 47.2%; optic disc swelling, 66.9%; and bilateral involvement, 41.7%. Among 101 patients who were followed up for ≥6 months, 48 (47.5%), 12 (11.9%), 19 (18.8%), 13 (12.9%), and 9 (8.9%) had been diagnosed with isolated ON, recurrent ON, multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and acute disseminated encephalomyelitis (ADEM)-related ON, respectively. At the latest visit, 81.9% and 71.1% had achieved BCVA of ≥20/40 and ≥ 20/25, respectively. Only disc swelling at presentation was associated with poor baseline BCVA (coefficient: 0.31, P=0.004) and greater improvement in BCVA (coefficient: 0.49, P = 0.001P=0.001); there were no significant associations between the baseline factors and final BCVA.

Conclusions

This study demonstrated pediatric ON-related clinical characteristics and visual outcomes in South Korea. Within this cohort, in about 40.6% of patients, ON was associated with other demyelinating diseases, namely, MS, NMOSD, and ADEM.

Rare and Atypical Presentations of Acute Disseminated Encephalomyelitis in Children: A Case Series

Acute disseminated encephalomyelitis (ADEM) is a monophasic demyelinating disorder of central nervous system occurring in children with a wide range of clinical manifestations after infection or vaccination. There are few case reports in literature, describing atypical presentations of ADEM with fever of unknown origin, autonomic dysfunction, complex movement disorders such as myoclonus, dystonia and chorea, acute psychosis and myocarditis. Here, we report four cases of ADEM with atypical features like uniocular blindness, myelin oligodendrocyte glycoprotein antibodies negative multiphasic disseminated encephalomyelitis, ADEM mimicking Guillain-Barre syndrome at presentation and isolated spinal ADEM. Treatment with high-dose steroids elicited an excellent neurological outcome in all patients. A high index of clinical suspicion along-with awareness of atypical features, magnetic resonance imaging and cerebrospinal fluid studies are of paramount importance in establishing ADEM diagnosis and initiation of early treatment for better outcome.

Assessment of Pediatric Optic Neuritis Visual Acuity Outcomes at 6 Months

Importance

Optic neuritis (ON) in children is uncommon. There are limited prospective data for visual acuity (VA) outcomes, associated diseases, and neuroimaging findings. Prospective data from a large sample would be useful for counseling families on treatment decisions and prognosis.

Objective

To prospectively study children with a first episode of ON, describe VA after 6 months, and ascertain the network's (Pediatric Eye Disease Investigator Group and Neuro-Ophthalmology Research Disease Investigator Consortium) ability to enroll pediatric patients with ON prospectively.

Design, Setting, and Participants

This nonrandomized cohort study was conducted from September 20, 2016, to July 20, 2018, at 23 sites in the United States and Canada in pediatric ophthalmology or neuro-ophthalmology clinics. A total of 44 children (aged 3-15 years) presented with a first episode of ON (visual loss, pain on eye movements, or both) within 2 weeks of symptom onset and at least 1 of the following in the affected eye: a distance high-contrast VA (HCVA) deficit of at least 0.2 logMAR below age-based norms, diminished color vision, abnormal visual field, or optic disc swelling. Exclusion criteria included preexisting ocular abnormalities or a previous episode of ON.

Main Outcomes and Measures

Primary outcomes were monocular HCVA and low-contrast VA at 6 months. Secondary outcomes were neuroimaging, associated diagnoses, and antibodies for neuromyelitis optica and myelin oligodendrocyte glycoprotein.

Results

A total of 44 children (mean age [SD], 10.2 [3.5] years; 26 boys [59%]; 23 White individuals [52%]; 54 eyes) were enrolled in the study. Sixteen patients (36%) had bilateral ON. Magnetic resonance imaging revealed white matter lesions in 23 children (52%). Of these children, 8 had myelin oligodendrocyte glycoprotein-associated demyelination (18%), 7 had acute disseminated encephalomyelitis (16%), 5 had multiple sclerosis (11%), and 3 had neuromyelitis optica (7%). The baseline mean HCVA was 0.95 logMAR (20/200), which improved by a mean 0.76 logMAR (95% CI, 0.54-0.99; range, -0.70 to 1.80) to 0.12 logMAR (20/25) at 6 months. The baseline mean distance low-contrast VA was 1.49 logMAR (20/640) and improved by a mean 0.72 logMAR (95% CI, 0.54-0.89; range, -0.20 to 1.50) to 0.73 logMAR (20/100) at 6 months. Baseline HCVA was worse in younger participants (aged <10 years) with associated neurologic autoimmune diagnoses, white matter lesions, and in those of non-White race and non-Hispanic ethnicity. The data did not suggest a statistically significant association between baseline factors and improvement in HCVA.

Conclusions and Relevance

The study network did not reach its targeted enrollment of 100 pediatric patients with ON over 2 years. This indicates that future treatment trials may need to use different inclusion criteria or plan a longer enrollment period to account for the rarity of the disease. Despite poor VA at presentation, most children had marked improvement by 6 months. Associated neurologic autoimmune diagnoses were common. These findings can be used to counsel families about the disease.

Optic neuritis in German children: clinical findings and association with multiple sclerosis

Purpose

Analysis of a cohort of pediatric optic neuritis patients concerning the epidemiology, disease progression, and association with multiple sclerosis (MS).

Methods

Retrospective, observational cohort study. From 2004 to 2018, all electronic medical files of patients younger than 18 years referred to a tertiary care clinic in Germany with the diagnosis optic neuritis have been analyzed.

Results

Sixty-nine patients were referred in the study period, 16 did not suffer under optic neuritis and were excluded. The median visual acuity of the remaining 53 patients was 0.07 at the baseline examination and 1.0 at the latest follow-up examination (decimal notation, median 2.1 years after baseline). Forty-two percent of the patients developed MS during the study period. Female sex (p = 0.028) as well as higher age (p = 0.0082) proved to be statistically significant risk factors for MS development.

Conclusion

The prognosis for restoring vision in pediatric optic neuritis was favorable. During the observation period, the risk of developing MS was overall 42% and 8% for patients younger than 11 years. The percentage of MS as underlying cause of optic neuritis does not differ remarkably between children older 10 years and adults.

Visual Outcomes and Clinical Manifestations of Pediatric Optic Neuritis in Indian Population: An Institutional Study

BACKGROUND

Optic neuritis in children is an uncommon disorder which usually occurs after a viral illness or vaccination and, less frequently, occurs as a manifestation of a demyelinating disorder. Pediatric optic neuritis usually is bilateral and presents with optic disc edema, recovers rapidly with steroid therapy, and generally has low conversion rate to multiple sclerosis or neuromyelitis optica spectrum disorder. We report the clinical features and treatment outcomes of pediatric optic neuritis in Indian population, for which little data are available.

METHODS

We reviewed the medical case records of patients with optic neuritis who were younger than 18 years, from 1999 to 2016. All patients were assessed and managed in the Neuro-Ophthalmology Department of Sankara Nethralaya, a unit of Medical Research Foundation and Pediatric Neurology Department of Kanchi Kamakoti-Childs Trust Hospital, Chennai, India.

RESULTS

One hundred seventeen eyes of 78 children with mean age of 11.84 (±4.58) years were identified. Forty-two (53.8%) were females and 36 (46.2%) were males. Thirty-nine patients (50%) had bilateral involvement and a similar number had unilateral involvement. Fifty-nine eyes (50.4%) had optic disc edema, 20 eyes (17.1%) had disc pallor, and 38 eyes (32.4%) had normal discs. Of 63 patients who had neuroimaging, 36 had MRI, and 27 underwent computed tomography. Eighty-four eyes (of 59 patients) received steroid therapy according to the protocol of the Optic Neuritis Treatment Trial (ONTT). Thirty-three eyes that were treated with other steroid protocols were excluded from the final visual outcome analyses. Sixty of the 84 eyes (72.3%) recovered visual acuity of 20/40 or better. Visual acuity improvement was statistically significant between initial and final visual acuity (logMAR) in our patients treated with the ONTT protocol (P ≤ 0.001).

CONCLUSIONS

Our Indian pediatric population had good visual recovery after steroid treatment for optic neuritis. Profound loss of visual acuity on presentation and bilateral involvement were significantly associated with poor visual outcome.